Patient Onboarding

Please complete the patient registration and consent form at least 48 hours prior to your appointment. This page may be printed and returned via email to

Food & Symptom Diary

Contact Details

Emergency Contact

Medicare Details

Usual GP Details

Referring Doctor (if not GP)

Reason for Appointment *

Your symptoms

What are the main symptoms you experience? Tick any that are relevant *

Gastrointestinal symptoms

Skin Problems


Nutritional Deficiencies



We require your consent to collect personal information about you. Please read this information carefully and sign where indicated below.

The Mind + Gut Specialist Clinic collects information from you for the primary purpose of providing quality health care. We will use the information you provide in the following ways:

  • Administrative purposes in running our clinic
  • Billing purposes including Medicare and Health Insurance Commission requirements
  • Retrieving medical history from other health providers
  • Disclosure to others involved in your health care including doctors and specialists outside this clinic. If you do not wish for contact to be made with others involved in your health care, please tick here:

I have read the information above and understand the reasons why information must be collected. I am also aware that the clinic follows guidelines to protect patient privacy in compliance with privacy legislation.

I consent to the handling of my information by this practice for the purposes set out above.

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

Book an appointment

We can help with disorders including irritable bowel syndrome, inflammatory bowel disease, coeliac disease, GORD and many others.

Our team of specialist gut-directed hypnotherapists, psychologists and dieticians are highly skilled and specific in their management approach.

We use evidence-based techniques that have been proven to improve long-term gastrointestinal symptoms. We see both adults and children. No referral is required to make an appointment with us.

Book Appointment